1984 lZ2-.3 1 " vO I1 �'\ �` LOT NO. IC✓
NO. STREET
P
CATION FOR GAS PERMIT
O
� OF CUPERTINO
Dat 19kv Permit No.
m-m
C` ( p T p�('� Fee $ '�—
paycatf f is id�6R6yln]ad�t 0he City of Cupertino for a permit to install gas pipes
and/or gas appliances as listed on the reverse side hereof, and agrees to install said pipes
and/or appliances in accordance with the provisions of the Plumbing Code of the City
of Cupertino, and all other laws applicable thereto.
Use of Premises, e
h OwnerU _ Address
gy : Address
CONTRACTOR, AGENT Approve d
Phone( 2 —`; �� �
PLUMBING INSPECT ,
Remarks (Check ✓)
Type of Appliance Units Fees New Replace Relocate
Gas Ranges
Wall Heaters
Gas Plates
Circulating Heaters
Blower Furnacesf-
Gas Fired Boilers
Warming Ovens
Percolators
Griddles
Steam Tables
Gravity Furnaces
Suspended Unit
Floor Furnace
we
Miscellaneous it
• (NAME TYPE)
II I'
I U
pp mnce Fees l� It
r;T --r
Inspected and Approved ..............:..�. .......__. ............... yam.....
DATE INSPECTOR {,
HOUSE GAS PIPING y, ,
Number of Outlets Size of. Maine JA
Gas Piping Fees 06
Tested and Approved . ... .. ... .�..�. .. ........ . . . . . .....`....A...
'TATE INSPECTOR [Ir
�v